SAN FRANCISCOMEDICINE - California Society of Addiction ...

Addiction and Recovery
Mainstreaming Mental Health
Integrating Substance Abuse and Mental Health Treatment into Primary Care
Robert M. McCarron, DO; Sergio Aguilar-Gaxiola, MD; and Caitlyn Meltvedt
The primary care setting has been
the de facto mental health care system
in the United States for several
decades. Up to 60% of all mental health
care services, including substance abuse
treatment, are delivered by primary care
practitioners (PCPs). Nonpsychiatrists—
mostly PCPs—prescribe more than 80%
of antidepressants, now the most widely
prescribed class of medications. 1 Primary
care settings are also the first point of
contact and the treatment site of choice
for minority, low-income patients. Primary
care is more available and easier to access
than specialty care, and many patients
view substance abuse and mental health
treatment in primary care settings as less
stigmatizing than care received in specialty
behavioral health settings.
Although this is the case, PCPs often do
not have time to address complex mental
health and substance abuse-related issues.
Moreover, even though depression, bipolar,
anxiety, and substance abuse disorders are
so prevalent in the primary care setting,
PCPs generally have disproportionate and
suboptimal residency and postresidency
psychiatric training. Unfortunately, the end
result for many who suffer from mental
illness is either ineffective treatment or, in
many cases, no treatment at all.
Meanwhile, the delivery of preventive
and primary care medicine to those
who have severe mental illness (SMI) is
also sorely lacking. In fact, those with SMI
live, on average, twenty-five years less
than those without SMI. 2 Although the
main cause for this dramatic disparity is
cardiovascular disease, people with mental
illness are much more likely to suffer from
chronic pulmonary disease, diabetes, sexually
transmitted infections, certain common
cancers, and sequelae related to substance
dependence. 3
In the eve of health care reform implementation,
there has recently been a strong
push by policy makers and clinic directors
to redesign the primary care setting and
more effectively integrate primary care and
mental health care. This is a logical move,
given the extraordinarily high prevalence
of mental and substance abuse disorders
and physical-mental comorbidities
encountered in the primary care setting.
The following is a brief summary of some
statewide initiatives designed to improve
the health of individuals with SMI and
co-occurring chronic medical disorders
through more effective partnerships
between mental health and primary care
providers.
CalMEND Pilot-Collaborative
to Integrate Primary Care and
Mental Health Services (CPCI)
This county-based program is sponsored
by the State of California Departments
of Health Care Services (DHCS) and
Mental Health (DMH), and it is structured
around the Institute for Health Care
Improvement Breakthrough Series Collaborative
model. The primary goal is to
effectively bring together mental health and
primary care practitioners and organizations
that share a commitment to making
major changes that produce significant and
sustainable breakthrough results.
CPCI will involve four to six county
behavioral health authorities and their
partner primary care organizations.
Each pilot site will have direct access to
faculty support and regularly scheduled
CPCI sponsored “learning sessions” that
are specifically designed to develop and
expand integrative care models. During the
eighteen-month project, various outcomes
will be measured, including an assessment
of how often standard-of-care primary
preventive strategies are used (such as
screening for diabetes and lipid abnormalities).
In mid-2011, each CPCI pilot site will
share its findings and achievements at a
CalMEND Learning Forum, with the goal
of improving medical and psychiatric care
for those who have SMI.
UC Davis: Integrated Medicine/
Psychiatry Ambulatory Residency
Training (IMPART)
Recent research has shown that
chronic physical conditions, including both
common chronic physical diseases (diabetes,
asthma, hypertension, heart disease,
and so on) and chronic pain conditions
(arthritis, back pain, headaches) are often
accompanied by common psychiatric disorders
such as major depression, anxiety
disorders, and substance abuse. The fact
that these psychiatric disorders often occur
within the context of comorbid chronic
physical conditions emphasizes the central
role that providers of primary health care
play in efforts to improve overall health
outcomes of both physical and psychiatric
disorders. Much of this co-occurring illness,
however, is not diagnosed or treated. With
Mental Health Services Act (MHSA) funding,
the University of California, Davis, has
developed and expanded two residency
programs—internal medicine/psychiatry
(IMP) and family medicine and psychiatry
(FMP) —that specifically train physicians
to better understand the mind-body connection
and physical-mental comorbidities
and to address this important health care
disparity. 4,5
16 17 San Francisco Medicine April June 2010 www.sfms.org